The Incidence of Venous Thromboembolism in Patients Undergoing Anterior Lumbar Interbody Fusion: A Proposed Thromboprophylactic Regime.

OBJECTIVE: To determine the safety and efficacy of the proposed venous thromboembolism (VTE) prophylaxis regime in patients undergoing anterior lumbar interbody fusion (ALIF) surgery. BACKGROUND: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are recognized complications after spine surgery, with rates in the literature ranging from 0% to 14% with some form of prophylaxis. Pharmacological thromboprophylaxis can cause postoperative bleeding and hematomas, which can result in significant neural compromise or permanent injury, and wound complications. ALIF surgery involves the handling and compression of major abdominal vessels during surgery and this adds to the risk of both arterial thrombosis and VTE. METHODS: A retrospective review of data, which were prospectively collected to evaluate the incidence of VTE in 200 consecutive patients undergoing ALIF following our VTE prophylaxis protocol. All patients had low molecular weight heparin, tinzaparin 4500 units subcutaneously on the evening before surgery, then daily for 3 to 5 days, then aspirin (acetylsalicylic acid) 150 mg daily plus lansoprazole 30 mg daily for 4 weeks after surgery. All patients had intermittent pneumatic compression of their calves and thighs intraoperatively and for 24 hours postoperatively then had early mobilization and thromboembolic deterrent stockings for 6 weeks. RESULTS: There was no incidence of any symptomatic VTE in the any of the 200 patients and no loss to follow-up. There was a 0% incidence of injury to the iliac vessels, symptomatic arterial occlusion, wound hematoma, major intraoperative bleeding, need for transfusion, symptomatic GI bleed, or retroperitoneal hematoma requiring intervention. CONCLUSIONS: The proposed VTE prophylactic regime is safe and efficacious and may decrease the incidence of symptomatic VTE in patients undergoing an ALIF procedure, and despite the use of chemical thromboprophylaxis, there is no evidence of bleeding complications as a result of using this regime. LEVEL OF EVIDENCE: 4.

All-inside versus inside-out meniscal repair: A systematic review and meta-analysis.

BACKGROUND: Meniscal repair using all-inside devices has garnered popularity compared to inside-out repair, yet few studies directly compare the two techniques in terms meniscal healing rates, surgical time, patient outcomes and incidence of complications. METHODS: A systematic literature review was performed using the Medline, Cochrane and Embase databases. English-language studies comparing all-inside and inside-out arthroscopic meniscal repair techniques directly were included. Randomised controlled trials (RCTs) and observational studies with at least 10 patients in each treatment arm were included. Meta-analyses were performed using a fixed effect (when I2 < 50%) or random effects model (I2 ≥ 50%). RESULTS: A total of 1042 studies were identified with seven being sui for inclusion (n = 505 patients). These comprised of one RCT two prospective and four retrospective, comparative, observational studies. Meta-analyses demonstrated that there was a significant reduction in operating time favouring all-inside repair (ratio of means [ROM] 0.62, 95% confidence interval [CI] 0.48-0.79; p = 0.0002) based on 3 studies (n = 208 patients). Based on 5 studies (n = 370 patients), there was no significant difference in meniscal healing rates between the groups (OR 1.26, 95% CI 0.52-3.10; p = 0.61). Nerve injury was more common after inside-out repair. There was a 85% reduction in the odds of nerve injury with the all-inside technique (OR 0.15, 95% CI 0.05-0.47; p = 0.0013). A qualitative data analysis suggested no difference in functional outcomes between the two techniques. CONCLUSIONS: All-inside meniscal repair is associated with reduced operative time and a lower odds of nerve injury complications compared to inside-out repair, without compromising meniscal healing or functional results.

Pilot study assessing functional outcome of tibial pilon fractures using the VSTORM method.

INTRODUCTION: The importance of long-term function and quality of life after trauma is well recognised, but gathering data is difficult. The Victoria State Trauma Registry (VSTORM) collects patient-reported outcome data after major trauma using telephone interview, following prospective enrolment. Key components of the VSTORM interview include use of the Glasgow Outcome Scale-Extended (GOS-E), collection of pre-injury demographics, use of 12-Item Short Form Health Survey (SF-12) and EQ-5D instruments as well as a pain numerical rating scale. The aim of this pilot study was to determine whether this methodology would capture clinically relevant data for a population sustaining a severe fracture associated with a wide range of potential outcomes. METHODS: Following ethical approval, patients with surgically managed tibial pilon fractures sustained between March 2002 and January 2010 were identified from the logbook of the senior author (IP) and contacted by post. After obtaining consent, a structured telephone interview was performed using the VSTORM questionnaire. RESULTS: Twenty-six of 45 patients consented to interview and 23/26 patients were contactable (13 male, 10 female, mean age 44 years). There were 17 Arbeitsgemeinschaft für Osteosynthesefragen (AO) Type C fractures, six Type B and seven Grade III open injuries. The mean visual analogue scale (VAS) score for health pre-injury was 88.9 (range 50-100, median 92) versus 71.5 (range 35-100, median 75) post-injury. Seven of 18 patients in full-time employment prior to injury did not return to work. Only one patient returned to previous employment. Nine of 23 patients reported moderate - to-extreme pain interfering with work; 16/23 patients had problems with mobility; 9/23 reported problems climbing stairs; and 14/23 of patients could not resume regular social/leisure activities. CONCLUSIONS: Prospective enrolment at the time of injury may improve follow-up. In those who participated, a credible range of outcomes were reported, comparable to recently published studies. This method appears efficient and acceptable to patients, and hence warrants larger-scale prospective evaluation.